Field Diagnosis and Management of Mild Traumatic Brain Injury mTBI for Deploying Family Physicians

1. Field Diagnosis and Management of Mild Traumatic Brain Injury (mTBI) for Deploying Family Physicians �1 Medical Section�s Perspective�

2. Agenda mTBI � non-combat Computer Neuropsychological Testing DVBIC Diagnosis Management MACE Management Ideas Blast Scenario

3. DISCLAIMER And now a word from our (my) lawyer: �The views expressed by this speaker are his and solely his and do not represent any official stance/policy of his unit, the Army Medical Department, the Department of the Army or the Department of Defense����

4. MildTraumatic Brain Injury (mTBI) �Signature wound� of the GWOT Up to 30% of service members evacuated from theater and seen at Walter Reed are diagnosed with mild TBI (mTBI) What is the exact # of mTBIs in Iraq or Afghanistan? Unclear but anecdotal survey report 30-40% of service members report at least 1 mTBI episode

5. Mild Traumatic Brain Injury (mTBI) Diagnosis and management is a challenge whether in combat, in garrison or on the playing field Sports Medicine Model for mTBI management Recognition by individuals and providers Avoid another mTBI while symptomatic Baseline Neuropsychological Testing

6. Mild Traumatic Brain Injury (mTBI) What defines a mTBI? Loss of Consciousness Yes/No Post Traumatic Amnesia Yes/No Altered Mental Status Yes/No Neurological Deficits Yes/No Headache Yes/No Behavioral Changes Yes/No Cognitive Changes Yes/No Post Concussion Syndrome

7. Mild Traumatic Brain Injury (mTBI) What defines a mTBI? Cantu � No LOC, <30 minutes PTA or post-concussion signs and symptoms last <30 minutes Colorado & AAN � No LOC <15 minutes PTA or concussion signs and symptoms

8. Mild Traumatic Brain Injury (mTBI) Physical Symptoms: Headache, Dizziness, Fatigue, Tinnitus, Nausea Disturbed sleep pattern and Photophobia Behavioral Symptoms: Irritability, Anxiety, Depression, Emotional labiality and Personality changes Cognitive Symptoms: Attention, Memory, Hand-eye coordination, Multi-tasking, Reasoning, Judgment, Executive Function

9. Mild Traumatic Brain Injury (mTBI)

10. Sports Related Management First do no harm!! Do not return to play/duty until patient is asymptomatic Numerous Sports Medicine management guidelines: Cantu, American Academy of Neurology, Colorado Medical Society, etc�. All vary a little on the specific dx of mild, moderate, severe. Must be asymptomatic at rest and with exertion to return to activity

11. Sports Related Management Does not return to play until asymptomatic Close observation and monitoring Appropriate Imaging Exertional Challenge Gradual return to activity Does not advance to next level if has symptoms

12. Sports Related Management Sports related mTBI management guidelines are improving and evolving However, combat isn�t a sport!!!! RTP early in sports maybe you end up missing the rest of the season RTD early in combat you may end of killing yourself or someone else You can always go to the bench or the sideline in a sporting event

13. Computer NP Testing Hotly debated topic!! To do or not to do Diagnostic tool v follow up tool? mTBI is primarily a clinical diagnosis NP testing is an adjunctive tool to help in the management of mTBI Objective score to show COC that Soldier is not back at his/her baseline.

14. Computer Neuropsychological (NP) Testing Various tests out there � most with pretty good sensitivity, specificity and reproducibility. Automated Neuropsychological Assessment Metrics (ANAM) Immediate Post-concussion Assessment Tool (ImPACT) Cogsport Designed to help us better diagnose concussions

15. Computer NP Testing Started baseline testing all operational personnel with ANAM approximately 5 yrs ago (fall 2004) Realized test was not sensitive or specific enough for our population Jul-Aug 07 changed to ImPACT and began to baseline EVERY Soldier May 08 ASD-HA mandated predeployment baseline neuropsych testing

16. Computer NP Testing - why we changed 35 yo AD/M involved in a parasailing accident Had baseline ANAM about 10 days prior to accident mTBI diagnosed with obvious changes in ANAM from baseline 6 weeks later ANAM back to baseline but clinically still symptomatic Work tasks, social skills�.

18. DVBIC Consensus Statement Deployed Setting http://dvbic.org/public_html/pdfs/Deployed_setting_CPG_10OCT08.pdf Point of injury care by non-provider through RTD CONUS Setting http://dvbic.org/pdfs/mTBI_recs_for_CONUS.pdf Good advice on acute management, red flags and short term management

21. Military Acute Concussion Evaluation Standardized Assessment of Concussion (SAC) McCrea M Standardized Mental Status Testing on the Sideline After Sport-Related Concussion Journal of Athletic Training 2001;36(3):274�279 A sideline MMSE � that aided ATCs in the dx and management of sports related mTBIs MACE is the military version of the SAC Patients score is the patients score regardless of who gives the test

25. Aid Bag MACE Card

26. Military Related Management Safety of patient and peers is paramount Long war mentality Exertional testing is important but mental processing is just as/if not more imporant These guys are extremely physically fit hard to stress them physically Mental processing; radios, decision making Everyone is a quarterback!! Mission simulation/testing prior to RTD

27. mTBI Management Summary Treat all traumatic life threatening injuries first�. Identify Soldiers with possible mTBI � actions, words, proximity, etc. As soon as tactically feasible complete MACE Upon RTB, if MACE is still abnormal, clinically not resolved or gut feeling Complete ImPACT testing and compare to baseline

28. mTBI Management Summary If ImPACT is normal � monitor the patient, consider exertional testing and if normal allow RTD If ImPACT is abnormal, restrict activity (operations and PT) and retest in 2 weeks If normal, exertional testing and if asymptomatic and otherwise normal RTD If abnormal, continue to restrict activity and obtain full neuropsychology testing.

29. Blast Overpressure Injuries

30. Blast Overpressure Injuries What is the exact pathophysiology and how should it be treated? Similar to or different from impact/sports related concussions? LOTS of work being done on this�.. May be an entirely different pathologic process but to early to tell Continue to treat like sports concussions or other TBIs

31. Blast Overpressure Injuries What is the exact pathophysiology and how should it be treated? Similar to or different from impact/sports related concussions? LOTS of work being done on this�.. May be an entirely different pathologic process but to early to tell Continue to treat like sports concussions or other TBIs

32. Blast Overpressure Injuries Is it possible to get a mTBI when the head/brain is not exposed to the blast? Anecdotal cases reported Pressure wave through the vascular system results in damage to the brain? Hard to recreate on animal models Always check the TMs Peltor headsets are not 100% effective

33. Blast Overpressure Injuries Circumstances surrounding the blast exposure are critical. Open air v closed confines Location relative to the blast Secondary and Tertiary Blast Effect

34. Patient Scenario Patient #1: Right near blast, approx 2 min LOC, minimal PTA, normalizes quickly Patient #2: In the room, No LOC, <5 min of confusion, 5 minutes PTA, mild HA, tinnitus, Patient #3: back corner of back room, No LOC, denies any symptoms fired the rounds into suicide bomber Patient #4: in the room, No LOC, No PTA, mild HA, can�t hear and has blood draining from bilateral EACs.

35. Patient Scenario Patient #1: MACE 27, HA controlled with tylenol, HA resolved in 24, nl MACE no issues with exertion Patient #2: Initial MACE 25, HA minimally controlled with tylenol, ImPACT close to baseline, next day MACE 27 still with HA. 2 days later normal, asymptomatic with ImPACT at baseline Patient #3: pulled security on ex-fil, didn�t get on helo, didn�t realize it was there. Initial MACE 24 with HA. ImPACT with obviously abnormal Patient #4: MACE nl, obviously rupture TMs with grossly abnl hearing.

36. Patient Scenario Patient #1: RTD in 24 hours no restrictions Patient #2: Exertional and complex task testing results in recurrent HA, MACE 27, retested in 2 days no HA and RTD about 5 days down time Patient #3: Next day MACE 25, still with mod-severe HA, 48 hours later MACE 25, sent home. 2 week ImPACT better but not at baseline. Full NP testing deficits identified and focused rehab begun. 6 weeks later all testing normal, gradual RTD Patient #4: RTD from mTBI standpoint